78R5866 AKH-D
By: Hopson H.B. No. 1238
A BILL TO BE ENTITLED
AN ACT
relating to the prompt payment of certain pharmacy claims by health
maintenance organizations and preferred provider benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 3A, Article 3.70-3C, Insurance Code, as
added by Chapter 1024, Acts of the 75th Legislature, Regular
Session, 1997, is amended by amending Subsection (d) and adding
Subsection (o) to read as follows:
(d) Not [If a prescription benefit claim is electronically
adjudicated and electronically paid, and the preferred provider or
its designated agent authorizes treatment, the claim must be paid
not] later than the 21st day after the date an insurer affirmatively
adjudicates a pharmacy claim that is electronically submitted, the
insurer shall:
(1) pay the total amount of the claim through
electronic funds transfer; or
(2) notify the pharmacy provider of the reasons for
denying payment of the claim [treatment is authorized].
(o) A transaction fee may not be charged for adjudication of
a claim submitted electronically.
SECTION 2. Section 843.339, Insurance Code, as effective
June 1, 2003, is amended to read as follows:
Sec. 843.339. DEADLINE FOR ACTION ON CERTAIN PRESCRIPTION
BENEFIT CLAIMS. (a) Not [If a health maintenance organization or
its designated agent authorizes treatment, a prescription benefit
claim that is electronically adjudicated and electronically paid
shall be paid not] later than the 21st day after the date a health
maintenance organization or the health maintenance organization's
designated agent affirmatively adjudicates a pharmacy claim that is
electronically submitted, the health maintenance organization
shall:
(1) pay the total amount of the claim through
electronic funds transfer; or
(2) notify the pharmacy provider of the reasons for
denying payment of the claim [on which the treatment is
authorized].
(b) A transaction fee may not be charged for adjudication of
a claim submitted electronically.
SECTION 3. This Act takes effect September 1, 2003, and
applies only to a payment to a pharmacy provider for claims
submitted to a health maintenance organization or an insurer on or
after that date.